New England Journal of Medicine 1993 (Jan 28); 328 (4): 246–252 ~ FULL TEXT
David M. Eisenberg, Ronald C. Kessler, Cindy Foster, Frances E. Norlock, David R. Calkins, and Thomas L. Delbanco
Background: Many people use unconventional therapies for health problems, but the extent of this use and the costs are not known. We conducted a national survey to determine the prevalence, costs, and patterns of use of unconventional therapies, such as acupuncture and chiropractic.
Methods: We limited the therapies studied to 16 commonly used interventions neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. We completed telephone interviews with 1539 adults (response rate, 67 percent) in a national sample of adults 18 years of age or older in 1990. We asked respondents to report any serious or bothersome medical conditions and details of their use of conventional medical services; we then inquired about their use of unconventional therapy.
Results: One in three respondents (34 percent) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The latter group had made an average of 19 visits to such providers during the preceding year, with an average charge per visit of $27.60. The frequency of use of unconventional therapy varied somewhat among sociodemographic groups, with the highest use reported by nonblack persons from 25 to 49 years of age who had relatively more education and higher incomes. The majority used unconventional therapy for chronic, as opposed to life-threatening, medical conditions. Among those who used unconventional therapy for serious medical conditions, the vast majority (83 percent) also sought treatment for the same condition from a medical doctor; however, 72 percent of the respondents who used unconventional therapy did not inform their medical doctor that they had done so. Extrapolation to the U.S. population suggests that in 1990 Americans made an estimated 425 million visits to providers of unconventional therapy. This number exceeds the number of visits to all U.S. primary care physicians (388 million). Expenditures associated with use of unconventional therapy in 1990 amounted to approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. This figure is comparable to the $12.8 billion spent out of pocket annually for all hospitalizations in the United States.
Conclusions: The frequency of use of unconventional therapy in the United States is far higher than previously reported. Medical doctors should ask about their patients' use of unconventional therapy whenever they obtain a medical history.
Address reprint requests to Dr. Eisenberg at the Division of General Medicine and Primary Care, Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215
From the
FULL TEXT Article
Discussion
We found that unconventional medicine has an enormous presence in the U.S. health care system. An estimated one in three persons in the U.S. adult population used unconventional therapy in 1990. The estimated number of visits made in 1990 to providers of unconventional therapy was greater than the number of visits to all primary care medical doctors nationwide, and the amount spent out of pocket on unconventional therapy was comparable to the amount spent out of pocket by Americans for all hospitalizations. Roughly 1 in 4 Americans who see their medical doctors for a serious health problem may be using unconventional therapy in addition to conventional medicine for that problem, and 7 of 10 such encounters take place without patients' telling their medical doctors that they use unconventional therapy. Furthermore, use is distributed widely across all sociodemographic groups.
There are limits to the representativeness of our sample because it was confined to households with telephones. People living in households without telephones, those in shelters or on the street, and those in institutions were not sampled. In addition, we excluded non-English-speakers and persons for whom the interview would be burdensome because of physical or mental impairment. The frequency and patterns of use of unconventional therapy among these subgroups (and among children) are not known.
As regards the generalizability of the responses of the 67 percent of the respondents who completed the interview, we made two sets of comparisons with preexisting national surveys. Our sample corresponded with the distribution of the subjects of the National Health Interview Survey [23] with respect to age, sex, race, social class, and other sociodemographic variables, suggesting that our sample was representative of the U.S. household population. Compared with the national Health and Nutrition Examination Survey, [26] however, our survey involved fewer people who reported poor health on a five-point scale of health status (3 percent vs. 7 percent). This underrepresentation of respondents with poor health reflects our exclusion of those for whom the survey would have been burdensome because of their physical incapacity. Since we found that persons who reported poor health had substantially higher rates of use of unconventional therapy than those who perceived themselves to be in better health (52 percent vs. 33 percent), the study design may have resulted in an underestimate of the use of unconventional therapy.
Unconventional therapies are generally used as adjuncts to conventional therapy, rather than as replacements for it. Users of unconventional therapy were more likely to see a medical doctor than a provider of unconventional therapy, and visits to providers for serious medical conditions in the absence of contact with a medical doctor were rare. Moreover, in contrast to previous reports of research involving patients with cancer, [6, 7, 9] no respondents in this national survey who identified cancer as a principal medical problem reported seeing a provider of unconventional therapy without also seeing a medical doctor for this condition.
Although much of the literature dealing with unconventional medical practices focuses on potentially life-threatening or debilitating illness, the use of unconventional therapy was not limited to life-threatening conditions. Projections from survey data indicate that millions of Americans used unconventional therapy for each of the conditions we studied, the majority of which are not life-threatening. Put somewhat differently, it is likely that virtually all medical doctors see patients who routinely use unconventional therapies. Indeed, for medical doctors currently caring for patients with back problems, anxiety, depression, or chronic pain, the odds are greater than one in three that a patient is simultaneously using unconventional therapy for these medical problems without disclosing this fact.
Our results also suggest that the use of unconventional therapy is not limited to the person's principal medical conditions. A full third of the respondents who used unconventional therapy in 1990 did not use it for any of their principal medical conditions. From this fact we infer that a substantial amount of unconventional therapy is used for nonserious medical conditions, health promotion, or disease prevention. However, these issues were not a focus of our inquiry.
Although users of unconventional therapy are more likely to be in contact with medical doctors than with providers of unconventional therapy, fewer than 3 in 10 users of unconventional therapy mention its use to their medical doctors. Moreover, roughly half of those who use unconventional therapy for their principal medical conditions have no supervision of this treatment by either a medical doctor or a provider of unconventional therapy. Extrapolations to the U.S. population suggest that approximately 20 million Americans fall into this unsupervised category.
Our observation that the majority of users of unconventional therapy did not discuss this therapy with their medical doctors suggests a deficiency in current patient-doctor relations. Perhaps this lack of communication derives from medical doctors' mistaken assumption that their patients do not routinely use unconventional therapies for serious medical problems. Perhaps medical doctors do not discuss the use of unconventional therapies because they lack adequate knowledge of these techniques. In either case, this failure to communicate is not in the best interest of the patients, since the use of unconventional therapy, especially if it is totally unsupervised, may be harmful [11-27].
Medical doctors should begin to ask their patients about their use of unconventional therapy whenever they obtain a history. Some doctors may be uncomfortable with this line of questioning. Nonetheless, as Kleinman and colleagues suggested more than a decade ago, [28-29] an exploration of the use of unconventional therapy and enhanced understanding of these practices will improve both communication between patients and doctors and clinical care. We suggest that medical schools include information about unconventional therapies and the clinical social sciences (anthropology and sociology) in their curriculums. The newly established National Institutes of Health Office for the Study of Unconventional Medical Practices should help promote scholarly research and education in this area.
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